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The AFFIRM study showed no difference in risk of stroke in patients who have converted to a normal rhythm with anti-arrhythmic treatment, compared to those who have only rate control.<ref name=pmid12466506/>
The AFFIRM study showed no difference in risk of stroke in patients who have converted to a normal rhythm with anti-arrhythmic treatment, compared to those who have only rate control.<ref name=pmid12466506/>


==ACC / AHA Guidelines- Pharmacological Rate Control During Atrial Fibrillation (DO NOT EDIT) <ref name="Epstein"> Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM III, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices). Circulation. 2008; 117: 2820–2840. PMID 18483207 </ref>==
==ACCF/AHA/HRS 2011 Focused Updated Guidelines- Pharmacological Rate Control During Atrial Fibrillation (DO NOT EDIT) <ref name="pmid16908781">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16908781 ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.] ''Circulation'' 114 (7):e257-354. [http://dx.doi.org/10.1161/CIRCULATIONAHA.106.177292 DOI:10.1161/CIRCULATIONAHA.106.177292] PMID: [http://pubmed.gov/16908781 16908781]</ref><ref name="pmid21382897">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21382897 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.] ''Circulation'' 123 (10):e269-367. [http://dx.doi.org/10.1161/CIR.0b013e318214876d DOI:10.1161/CIR.0b013e318214876d] PMID: [http://pubmed.gov/21382897 21382897]</ref>==
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===Class I===
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]===
1. Measurement of the heart rate at rest and control of the rate using pharmacological agents (either a [[beta blocker]] or non [[dihydropyridine]] [[calcium channel antagonist]], in most cases) are recommended for patients with persistent or permanent [[AF]]. ''(Level of Evidence: B)''
'''1.''' Measurement of the [[heart rate]] at rest and control of the rate using pharmacological agents (either a [[beta blocker]] or non [[dihydropyridine]] [[calcium channel antagonist]], in most cases) are recommended for patients with persistent or permanent [[AF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''


2. Intravenous administration of [[digoxin]] or [[amiodarone]] is recommended to control the heart rate in patients with [[AF]] and [[heart failure]] who do not have an accessory pathway. ''(Level of Evidence: B)''
'''2.''' In the absence of preexcitation, intravenous administration of [[beta blockers]] ([[esmolol]], [[metoprolol]], or [[propranolol]]) or nondihydropyridine [[CCB|calcium channel antagonists]] ([[verapamil]], [[diltiazem]]) is recommended to slow the ventricular response to [[AF]] in the acute setting, exercising caution in patients with [[hypotension]] or [[heart failure]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''  


3. In patients who experience symptoms related to [[AF]] during activity, the adequacy of heart rate control should be assessed during exercise, adjusting pharmacological treatment as necessary to keep the rate in the physiological range. ''(Level of Evidence: C)''
'''3.''' Intravenous administration of [[digoxin]] or [[amiodarone]] is recommended to control the heart rate in patients with [[AF]] and [[heart failure]] who do not have an accessory pathway. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''


4. [[Digoxin]] is effective following oral administration to control the heart rate at rest in patients with [[AF]] and is indicated for patients with [[heart failure]], [[LV dysfunction]], or for sedentary individuals. ''(Level of Evidence: C)''
'''4.''' In patients who experience symptoms related to [[AF]] during activity, the adequacy of heart rate control should be assessed during exercise, adjusting pharmacological treatment as necessary to keep the rate in the physiological range. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


===Class IIa===
'''5.''' [[Digoxin]] is effective following oral administration to control the heart rate at rest in patients with [[AF]] and is indicated for patients with [[heart failure]], [[LV dysfunction]], or for sedentary individuals. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
1. A combination of [[digoxin]] and either a [[beta blocker]] or non [[dihydropyridine]] [[calcium channel antagonist]] is reasonable to control the heart rate both at rest and during exercise in patients with [[AF]]. The choice of medication should be individualized and the dose modulated to avoid [[bradycardia]]. ''(Level of Evidence: B)''


2. It is reasonable to use [[ablation]] of the [[AV node]] or accessory pathway to control heart rate when pharmacological therapy is insufficient or associated with side effects. ''(Level of Evidence: B)''
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]===
'''1.''' A combination of [[digoxin]] and either a [[beta blocker]] or non [[dihydropyridine]] [[calcium channel antagonist]] is reasonable to control the heart rate both at rest and during exercise in patients with [[AF]]. The choice of medication should be individualized and the dose modulated to avoid [[bradycardia]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''


3. Intravenous [[amiodarone]] can be useful to control the heart rate in patients with [[AF]] when other measures are unsuccessful or contraindicated. ''(Level of Evidence: C)''
'''2.''' It is reasonable to use [[ablation]] of the [[AV node]] or accessory pathway to control heart rate when pharmacological therapy is insufficient or associated with side effects. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''


4. When electrical [[cardioversion]] is not necessary in patients with [[AF]] and an accessory pathway, intravenous [[procainamide]] or [[ibutilide]] is a reasonable alternative. ''(Level of Evidence: C)''
'''3.''' Intravenous [[amiodarone]] can be useful to control the heart rate in patients with [[AF]] when other measures are unsuccessful or contraindicated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


===Class IIb===
'''4.''' When electrical [[cardioversion]] is not necessary in patients with [[AF]] and an accessory pathway, intravenous [[procainamide]] or [[ibutilide]] is a reasonable alternative. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
1. When the ventricular rate cannot be adequately controlled both at rest and during exercise in patients with [[AF]] using a [beta blocker]], non [[dihydropyridine]] [[calcium channel antagonist]], or [[digoxin]], alone or in combination, oral [[amiodarone]] may be administered to control the heart rate. ''(Level of Evidence: C)''


2. Intravenous [[procainamide]], [[disopyramide]], [[ibutilide]], or [[amiodarone]] may be considered for hemodynamically stable patients with [[AF]] involving conduction over an accessory pathway. ''(Level of Evidence: B)''
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]===
'''1.''' When the ventricular rate cannot be adequately controlled both at rest and during exercise in patients with [[AF]] using a [beta blocker]], non [[dihydropyridine]] [[calcium channel antagonist]], or [[digoxin]], alone or in combination, oral [[amiodarone]] may be administered to control the heart rate. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


3. When the rate cannot be controlled with pharmacological agents or [[tachycardia]]-mediated [[cardiomyopathy]] is suspected, [[catheter ablation|catheter-directed ablation]] of the [[AV node]] may be considered in patients with [[AF]] to control the heart rate. ''(Level of Evidence: C)''
'''2.''' Intravenous [[procainamide]], [[disopyramide]], [[ibutilide]], or [[amiodarone]] may be considered for hemodynamically stable patients with [[AF]] involving conduction over an accessory pathway. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
 
'''3.''' When the rate cannot be controlled with pharmacological agents or [[tachycardia]]-mediated [[cardiomyopathy]] is suspected, [[catheter ablation|catheter-directed ablation]] of the [[AV node]] may be considered in patients with [[AF]] to control the heart rate. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
    
    
===Class III===
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]===
1. [[Digitalis]] should not be used as the sole agent to control the rate of ventricular response in patients with paroxysmal [[AF]]. ''(Level of Evidence: B)''
'''1.''' [[Digitalis]] should not be used as the sole agent to control the rate of ventricular response in patients with paroxysmal [[AF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''


2. [[Catheter ablation]] of the [[AV node]] should not be attempted without a prior trial of medication to control the ventricular rate in patients with [[AF]]. ''(Level of Evidence: C)''
'''2.''' [[Catheter ablation]] of the [[AV node]] should not be attempted without a prior trial of medication to control the ventricular rate in patients with [[AF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


3. In patients with decompensated [[heart failure|HF]] and [[AF]], intravenous administration of a non [[dihydropyridine]] [[calcium channel antagonist]] may exacerbate hemodynamic compromise and is not recommended. ''(Level of Evidence: C)''
'''3.''' In patients with decompensated [[heart failure|HF]] and [[AF]], intravenous administration of a non [[dihydropyridine]] [[calcium channel antagonist]] may exacerbate hemodynamic compromise and is not recommended. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''


4. Intravenous administration of [[digitalis]] [[glycoside]]s or non [[dihydropyridine]] [[calcium channel antagonists]] to patients with [[AF]] and a [[pre-excitation syndrome]] may paradoxically accelerate the ventricular response and is not recommended. ''(Level of Evidence: C)''}}
'''4.''' Intravenous administration of [[digitalis]] [[glycoside]]s or non [[dihydropyridine]] [[calcium channel antagonists]] to patients with [[AF]] and a [[pre-excitation syndrome]] may paradoxically accelerate the ventricular response and is not recommended. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''}}


==See Also==
==Vote on and Suggest Revisions to the Current Guidelines==
* [[The Living Guidelines: Diagnosis and Management of Atrial Fibrillation | The AF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]
* [[The Living Guidelines: Diagnosis and Management of Atrial Fibrillation | The AF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]


==Sources==
==Guideline Resources==
* The ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation <ref name="Fuster"> Fuster V, Ryden LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S. ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation- Executive Summary: executive summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidlines for the Management of Patients With Atrial Fibrillation): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006; 114: 700-752. PMID 16908781 </ref>
*[http://content.onlinejacc.org/cgi/reprint/48/4/e149.pdf ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation] <ref name="pmid16908781">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16908781 ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.] ''Circulation'' 114 (7):e257-354. [http://dx.doi.org/10.1161/CIRCULATIONAHA.106.177292 DOI:10.1161/CIRCULATIONAHA.106.177292] PMID: [http://pubmed.gov/16908781 16908781]</ref>
 
*[http://circ.ahajournals.org/content/123/10/e269.full.pdf 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation] <ref name="pmid21382897">Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21382897 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.] ''Circulation'' 123 (10):e269-367. [http://dx.doi.org/10.1161/CIR.0b013e318214876d DOI:10.1161/CIR.0b013e318214876d] PMID: [http://pubmed.gov/21382897 21382897]</ref>


==References==
==References==
{{reflist|2}}
{{reflist|2}}


{{Electrocardiography}}
{{Electrocardiography}}

Revision as of 15:20, 29 October 2011

Atrial Fibrillation Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Atrial Fibrillation from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Special Groups

Postoperative AF
Acute Myocardial Infarction
Wolff-Parkinson-White Preexcitation Syndrome
Hypertrophic Cardiomyopathy
Hyperthyroidism
Pulmonary Diseases
Pregnancy
ACS and/or PCI or valve intervention
Heart failure

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

EKG Examples
A-Fib with LBBB

Chest X Ray

Echocardiography

Holter Monitoring and Exercise Stress Testing

Cardiac MRI

Treatment

Rate and Rhythm Control

Cardioversion

Overview
Electrical Cardioversion
Pharmacological Cardioversion

Anticoagulation

Overview
Warfarin
Converting from or to Warfarin
Converting from or to Parenteral Anticoagulants
Dabigatran

Maintenance of Sinus Rhythm

Surgery

Catheter Ablation
AV Nodal Ablation
Surgical Ablation
Cardiac Surgery

Specific Patient Groups

Primary Prevention

Secondary Prevention

Supportive Trial Data

Cost-Effectiveness of Therapy

Case Studies

Case #1

Atrial fibrillation rate control On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Atrial fibrillation rate control

CDC on Atrial fibrillation rate control

Atrial fibrillation rate control in the news

Blogs on Atrial fibrillation rate control

Directions to Hospitals Treating Atrial fibrillation rate control

Risk calculators and risk factors for Atrial fibrillation rate control

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Rate control

Rate control is achieved with medications that work by increasing the degree of block at the AV node, effectively decreasing the number of impulses that conduct to the ventricles. This can be accomplisheddone with:

In addition to these agents, amiodarone has some AV node blocking effects (particularly when administered intravenously), and can be used in individuals when other agents are contraindicated or ineffective (particularly due to hypotension).

Rate control versus rhythm control

AF can cause disabling and annoying symptoms. Palpitations, angina, lassitude (weariness), and decreased exercise tolerance are related to rapid heart rate and inefficient cardiac output caused by AF. Furthermore, AF with a persistent rapid rate can cause a form of heart failure called tachycardia induced cardiomyopathy. This can significantly increase mortality and morbidity, which can be prevented by early and adequate treatment of the AF.

There are two ways to approach these symptoms: rate control and rhythm control. Rate control treatments seek to reduce the heart rate to normal, usually 60 to 100 beats per minute. Rhythm control seeks to restore the normal heart rhythm, called normal sinus rhythm. Studies suggest that rhythm control is mainly a concern in newly diagnosed AF, while rate control is more important in the chronic phase. Rate control with anticoagulation is as effective a treatment as rhythm control in long term mortality studies, the AFFIRM Trial.[1]

The AFFIRM study showed no difference in risk of stroke in patients who have converted to a normal rhythm with anti-arrhythmic treatment, compared to those who have only rate control.[1]

ACCF/AHA/HRS 2011 Focused Updated Guidelines- Pharmacological Rate Control During Atrial Fibrillation (DO NOT EDIT) [2][3]

“

Class I

1. Measurement of the heart rate at rest and control of the rate using pharmacological agents (either a beta blocker or non dihydropyridine calcium channel antagonist, in most cases) are recommended for patients with persistent or permanent AF. (Level of Evidence: B)

2. In the absence of preexcitation, intravenous administration of beta blockers (esmolol, metoprolol, or propranolol) or nondihydropyridine calcium channel antagonists (verapamil, diltiazem) is recommended to slow the ventricular response to AF in the acute setting, exercising caution in patients with hypotension or heart failure. (Level of Evidence: B)

3. Intravenous administration of digoxin or amiodarone is recommended to control the heart rate in patients with AF and heart failure who do not have an accessory pathway. (Level of Evidence: B)

4. In patients who experience symptoms related to AF during activity, the adequacy of heart rate control should be assessed during exercise, adjusting pharmacological treatment as necessary to keep the rate in the physiological range. (Level of Evidence: C)

5. Digoxin is effective following oral administration to control the heart rate at rest in patients with AF and is indicated for patients with heart failure, LV dysfunction, or for sedentary individuals. (Level of Evidence: C)

Class IIa

1. A combination of digoxin and either a beta blocker or non dihydropyridine calcium channel antagonist is reasonable to control the heart rate both at rest and during exercise in patients with AF. The choice of medication should be individualized and the dose modulated to avoid bradycardia. (Level of Evidence: B)

2. It is reasonable to use ablation of the AV node or accessory pathway to control heart rate when pharmacological therapy is insufficient or associated with side effects. (Level of Evidence: B)

3. Intravenous amiodarone can be useful to control the heart rate in patients with AF when other measures are unsuccessful or contraindicated. (Level of Evidence: C)

4. When electrical cardioversion is not necessary in patients with AF and an accessory pathway, intravenous procainamide or ibutilide is a reasonable alternative. (Level of Evidence: C)

Class IIb

1. When the ventricular rate cannot be adequately controlled both at rest and during exercise in patients with AF using a [beta blocker]], non dihydropyridine calcium channel antagonist, or digoxin, alone or in combination, oral amiodarone may be administered to control the heart rate. (Level of Evidence: C)

2. Intravenous procainamide, disopyramide, ibutilide, or amiodarone may be considered for hemodynamically stable patients with AF involving conduction over an accessory pathway. (Level of Evidence: B)

3. When the rate cannot be controlled with pharmacological agents or tachycardia-mediated cardiomyopathy is suspected, catheter-directed ablation of the AV node may be considered in patients with AF to control the heart rate. (Level of Evidence: C)

Class III

1. Digitalis should not be used as the sole agent to control the rate of ventricular response in patients with paroxysmal AF. (Level of Evidence: B)

2. Catheter ablation of the AV node should not be attempted without a prior trial of medication to control the ventricular rate in patients with AF. (Level of Evidence: C)

3. In patients with decompensated HF and AF, intravenous administration of a non dihydropyridine calcium channel antagonist may exacerbate hemodynamic compromise and is not recommended. (Level of Evidence: C)

4. Intravenous administration of digitalis glycosides or non dihydropyridine calcium channel antagonists to patients with AF and a pre-excitation syndrome may paradoxically accelerate the ventricular response and is not recommended. (Level of Evidence: C)

”

Vote on and Suggest Revisions to the Current Guidelines

Guideline Resources

References

  1. ↑ 1.0 1.1 Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, Kellen JC, Greene HL, Mickel MC, Dalquist JE, Corley SD (2002). "A comparison of rate control and rhythm control in patients with atrial fibrillation". N Engl J Med. 347 (23): 1825–33. PMID 12466506
  2. ↑ 2.0 2.1 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 114 (7):e257-354. DOI:10.1161/CIRCULATIONAHA.106.177292 PMID: 16908781
  3. ↑ 3.0 3.1 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 123 (10):e269-367. DOI:10.1161/CIR.0b013e318214876d PMID: 21382897


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